CONTINUING EDUCATION

Psychological inuences on the timing of orthodontic treatment

Alice W. Tung, BS,a and H. Asuman Kiyak, MA, PhDb Seattle, Wash. Debates about the ideal timing of orthodontic treatment have focused on issues of biologic development and readiness. In this article we examine psychologic issues that should be considered in the decision to initiate orthodontics in the younger child or to wait until adolescence or later. Psychologic development during the preadolescent and adolescent stages may inuence the childs motive for, understanding of, and adherence to treatment regimens. Results of a study of some personality characteristics, motives, and aesthetic values of young phase I patients are presented. Questionnaires were completed by 75 children (mean age 10.85 years, 52.1% female, 84% white) and their parents. Childrens perceived reasons for treatment were consistent with their parents reports (2 76.08, p .001); most were referred for crowded teeth (56%) and overbite (17.3%). Although body image and self-concept scores were within the normal range, both children and their parents expected the most improvement in self-image and oral function, with greater expectations by parents on self-image (p .0001), oral function (p .0001), and social life (p .03) than children themselves. Although white and minority children were similar in their self-ratings and expectations from orthodontics, the former were more critical in their aesthetic judgments. They rated faces with crowded teeth (p .02), overbite (p .02), and diastema (p .01) more negatively than did ethnic minorities. These results suggest that younger children are good candidates for Phase I orthodontics, have high self-esteem and body-image, and expect orthodontics to improve their lives. White children who have been referred for Phase I orthodontics appear to have a narrower range of aesthetic acceptability than minority children. (Am J Orthod Dentofacial Orthop 1998;113:29-39.)

acial aesthetics has been found to be a signicant determinant of self and social perceptions and attributions.1,2 These perceptions of facial aesthetics inuence psychological development from early childhood to adulthood. The infants visual preference for human faces has been conrmed in many psychological studies.3 This behavior is adaptive; recognition of familiar faces is critical for an infants survival. By the age of 6 months, children can discriminate between familiar and unfamiliar faces.4 By the age of 6 years, children have internalized cultural values of physical attractiveness. By age 8 their criteria for attractiveness are the same as those of adults.5 A teachers perceptions of a childs attractiveness can inuence the teachers expectations and evaluation of the child.6 Similar results were found in a study conducted in Nigeria.7 Children perceived as more attractive are not only
From the Department of Oral and Maxillofacial Surgery, University of Washington. a Dental student. b Professor of Oral and Maxillofacial Surgery. Ms. Tung was supported by a University of Washington Summer Research Fellowship, NIDR grant T35-DE07150. Copyright 1998 by the American Association of Orthodontists. 0889-5406/98/$5.00 0 8/5/86269

more socially accepted by their peers, they are also believed to be more intelligent and to possess better social skills.3,8-11 In addition, people perceived as attractive by their peers are considered more desirable as friends than are unattractive people.3 Employees perceived as more attractive by their supervisors are given better job-performance ratings than less attractive employees.12 Thus, individuals who are perceived by their parents, peers and employers to be attractive are more likely to experience positive social interactions and evaluations. Studies of laypersons responses to attractive and unattractive faces of strangers have shown that attractive persons are described as more competent in interpersonal relationships and friendlier than people with unattractive faces, even when the test subjects had no additional knowledge about the faces being examined.13
The Role of Teeth in Appearance

The appearance of the mouth and smile plays an important role in judgments of facial attractiveness.14 This nding is consistent with the results of two previous national surveys that showed most Americans believe dental appearance is very im29

30 Tung and Kiyak

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

Fig. 1. Social factors affecting self-concept.

portant in social interactions, particularly in young peoples selection of dating partners.15,16 Children of normal dental appearance are judged to be betterlooking, more desirable as friends, and more intelligent.17 Children have reported that the appearance of their teeth is a common target of teasing.18 In particular, malocclusions in the anterior region are the most conspicuous and raise the childs greatest concerns.19-21 Helm and colleagues have found that overjet, extreme deep bite and crowding are associated with the most unfavorable self-perceptions of teeth.19 Shaw has found that an overjet of 7 mm or more, anterior crowding and deep bite are associated with a childs report of being teased.17,18 Overjet has also been found to be the most signicant predictor of the decision to seek orthodontic correction, especially in children referred for treatment by their parents.20 Some researchers have examined laypersons evaluations of malocclusions in terms of attractiveness. The following classes have been ranked from most to least attractive: Class I, open bite, Class II, and Class III,22 but patients with Class II malocclusion have been found to be signicantly more motivated to seek treatment than Class III patients.23 Contrary to the ndings of these studies, which comprised mostly white patients, research with Asian subjects has revealed a different pattern of perceived dental attractiveness of malocclusion types. A study in Singapore revealed that Class III malocclusion is ranked as more attractive than Class II.24 Malocclusions consisting of overjet, deep bite and overcrowding have been associated with the most negative self-evaluations among Danish adults.19 This self-perception of dental aesthetics

has been suggested as the most common predictor of the seeking of treatment.20,25,26 Perceived facial appearance has also been found to be an important predictor of the decision to undergo facial surgery for improvement of dental appearance.6 Perceived need for treatment does not necessarily reect an individuals actual clinical need as assessed by an orthodontist.27 The demand, or selfperception of need, for orthodontic treatment is greater in female subjects than in male subjects,24,27,28 among white subjects, in urban settings and among children of higher socioeconomic status. In contrast, actual clinical need was found in these same studies to be greater for males and whites and equal across socioeconomic strata and in urban vs. rural settings.27 In Asian subjects the perceived need for orthodontic treatment has been found to be inversely correlated with the rank order of malocclusion attractiveness.24 In descending order of attractiveness ratings, children with Class I, open bite, Class III, Class II, anterior crowding, and deep bite ranked themselves as increasingly more likely to need treatment.
Self-Concept and Appearance

The individuals interactions with and responses from others may inuence the development of selfconcept.6 Self-concept is dened as the perception of ones own ability to master or deal effectively with the environment.29 Developmental psychologists generally agree that a childs self-concept develops from the reected appraisal that he or she receives from others.30 In other words, self-concept is affected by the reactions of others toward the child. Self-concept also depends on social comparisons and self-attributions by the child. Fig. 1 illustrates the variety of factors that inuence self-concept. It is important to note that researchers have consistently found that self-concept is related more to the individuals perceptions of others evaluations than to objective evaluations by others.3,30 As discussed earlier, facial attractiveness plays an important role in social acceptance by peers. A positive relationship also exists between physical/facial attractiveness and interpersonal popularity, as well as others favorable evaluations of personality, social behaviors, and intellectual expression.31 Females have consistently been found to have more negative body image and self-concept scores. This phenomenon begins in adolescence, when girls become more concerned about their physical appearance and weight. Although pubertal changes increase the self-consciousness of boys and girls, the

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No. 1

Tung and Kiyak 31

latter are more inuenced by these rapid changes in their physical appearance, and they continue to attach more importance to these external characteristics into adulthood.32-34 Parental concern most likely stems from the parents hope that the child will conform to their own and societys ideals of facial attractiveness.35 It has been suggested that parental inuence based on dental aestheticsnot necessarily malocclusion severitymay be the main motivating factor for children to seek orthodontic treatment.36 These ndings are similar to those of Dann and colleagues37; the degree of malocclusion does not affect the decision to undergo treatment as much as the perceived aesthetics of the malocclusion. Although overall self-concept has not been found to be altered by orthodontic treatment, some components of self-concept, perceptions of appearance by others (e.g., parents and peers), and body image have been found to improve after treatment.1,6,34 In children with more conspicuous facial impairments such as cleft lip or palate, correction may result in improved school performance and social acceptance.38,39
Treatment During Preadolescence or Adolescence?

The decision of whether to treat a patient in childhood or adolescence raises several issues related to the developmental stages of preadolescence and adolescence.40-42 One of these issues is the concern with adherence. Treatment adherence is inuenced by a childs sex and age. In general, girls are more likely to adhere to treatment recommendations than boys.40,41 Preadolescent children have been found to be more adherent to rules for the use of removable appliances than adolescents.41 For this reason it has been suggested that treatment begin after age 6 and be completed before the onset of puberty.41 Other predictors of greater adherence include high self-esteem, optimism regarding the future, and low social alienation.40 Children experience major changes in these aspects of the self as they move from early childhood through the teen years. According to Eriksons theory of psychosocial development,43 the preadolescent experiences the stage of industry vs. inferiority when social and academic skills develop, children begin to compare their capabilities in these areas with peers, and they increasingly recognize that they can achieve competence through their own initiative. The adolescent goes through a period of identity vs. role confu-

sion, Eriksons fth stage of psychosocial development. This is a period of role confusion for many adolescents as their physical selves mature into their future adult selves yet they are still treated as children. The goal of this developmental stage is the search for identity, or a feeling of being at home in ones body, a sense of knowing where one is going, and an inner assuredness of anticipated recognition from those who count.43 Adolescence is often associated with increased self-consciousness, confusion about identity and acceptance by others, and concerns about recognition from adults and peers. Younger children are inuenced greatly by their parents and other adults (e.g., teachers, health care providers). As the child enters adolescence, however, peers assume a greater role in their lives, especially in terms of self-image.3 Peers often serve as a standard of comparison and implicit or explicit critics of the adolescents appearance, dress, activities, and interests. The ambiguity and uidity of these peer relationships and the reliance on peer acceptance and ambivalence about parental authority can lead to social alienation but can also provide adolescents with important challenges that help them achieve a sense of identity or inner assuredness. Indeed, the social, emotional, and, often, academic crises of adolescence are viewed by some personality theorists as a healthy process of reconstructing ones identity and selfconcept.43,44 Other developmental psychologists have found that self-concept does undergo some changes during adolescence but that these changes are not necessarily traumatic.45,46 The increasing signicance of peer acceptance for adolescents results in greater need for social comparison. Girls in particular express greater concern about their facial features, especially when certain features (teeth, nose, hair) are different from those of their peers. Boys are not immune to the social-comparison process, but they are more likely to express concerns with their athletic ability and physical size compared with their peers. This increased focus on the self relative to his or her peers may help or hinder the childs success with orthodontic interventions. If the adolescent has signicant concerns about the appearance of his or her teeth and has friends who are undergoing or have undergone orthodontics, they can serve as role models for the child. This role-modeling can result in greater cooperation with the treatment regimen. If, however, the child is absorbed in other developmental tasks of adolescence, it may be the wrong time to initiate treatment. Research by Peevers47 on

32 Tung and Kiyak

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

Age (years):

13

17

Past: Future: Change: No Change

33 22 0 45

54 29 0 17

73 4 11.5 11.5

59 22.5 13 5.5

*Summarized from Peevers (1987)47 Represents percentage giving response with this time perspective.

Fig. 2. Time orientation of children (%).

childrens past, future, and current perspectives, and their perception of change vs. constancy in themselves, provides further evidence that adolescence is a time of identity confusion. Using a qualitative methodology, Peevers analyzed self-descriptions of children aged 6, 9, 13, and 17 years. Childrens descriptions of their lives were coded in terms of continuity (past, present, future orientation), distinctness of the self as a unique being, and self-reection. Distinctness was least evident at age 6 and most evident at ages 9 and 13. Self-reective descriptions did not emerge in children until age 17. Fig. 2 illustrates age differences in childrens time orientation, or their perceptions of themselves as having a past, present, and future. It is evident that adolescents in this study focused most on their past selves, least on their future. Yet they were more likely than the younger subjects to perceive changes in themselves since early childhood (e.g., Since middle school, Ive changed a lot in my personality). In contrast, the 6- and 9-year-olds were more likely than adolescents to think of their future selves (e.g., I hope someday Ill become an artist) and to view themselves as having experienced few changes in their lives and in their personalities so far. These differences may have implications for childrens attitudes toward, and adherence to, orthodontic treatment. Adolescents focused on the here and now may have more difculty with long-term adherence in the interests of future improvements in their oral function and appearance.
Description of Current Study

opmental perspective, we conducted a study of such children and their parents. We administered a questionnairedesigned to assess self-concept and body image, ability to dene the orthodontic problem for which they had been referred, and their expectations from treatmentto children. Parents were included in the study to obtain factual information about the child and treatment decisions, as well as their perceptions of treatment need and the childs level of self-care. This study was therefore an attempt to explore some of the issues of child development that have been raised as potential barriers to Phase I treatment. Although some orthodontists are concerned that the younger child is not psychologically ready for treatment and that the parent of a younger child plays a greater role in the decision and treatment phases than with adolescents, these concerns may be alleviated by the recognition that younger children are generally aware of their malocclusion, concerned about improving it, and less burdened with the stresses of adolescence described above.
MATERIAL AND METHODS Sample The sample comprised children ages 9 to 12 years in fourth or fth grade in three Seattle-area schools and children in the same age range who had been examined by an orthodontist in Anchorage, Alaska. To control for the effects of socioeconomic status and location, we ensured that the children were representative of middle- to upperincome groups in these communities. A total of 160 parents were contacted from one public and two private schools in Seattle through the principal or vice principal of each school. In the Anchorage area, parents of 37 children were contacted by an orthodontist who had screened these patients in the preceding 2 years. These families were sent a letter describing the purpose of the study and asking them to return an attached postcard with the following questions: (1) Had the child ever received a recommendation to undergo early orthodontic treatment? (2) Had the child undergone the treatment, or was he or she currently in treatment? and (3) If the treatment was recommended, would the child and parent be willing to complete questionnaires regarding their decisions? One hundred forty-eight postcards were returned (92.5% response rate); 98 of these children had been referred for orthodontics and were willing to participate in the study. Among the remainder, 31 had never been referred for treatment and 9 had been referred but did not want to participate in the study. Packets containing questionnaires for one parent and the subject child were mailed to the 98 families who expressed interest in the study. Parents and children in this group also were sent institutional review boardapproved consent forms for the parent and an assent form for the child. The cover letter

To determine whether younger children referred for Phase I orthodontics are prepared from a devel-

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No. 1

Tung and Kiyak 33 verbal anchors to read (3) it is much worse after orthodontics to (3) it is better after orthodontics. Recently this instrument was used in a study by Phillips and colleagues49 to determine the motivations of patients with skeletal disharmony for seeking treatment. The instrument was modied by these investigators to include 24 questions with two additional dimensions, but these items were not included in the version used in our study. We calculated total scores for each dimension by adding the four items representing each of the rst three dimensions (yielding scores ranging from 12 to 12) and the two items representing the fourth dimension. To compare scores across the four dimensions, we multiplied scores on the fourth dimension (general health) by two, thereby allowing a range of 12 to 12 on all four dimensions. Previous studies of adults undergoing surgical orthodontics have revealed that body image is generally lower in that population than in conventional orthodontic patients but that it improves signicantly for the former while showing only a mild increase for the latter.50 The measure used in these earlier studies was the Secord and Jourard51 Body Cathexis Scale, adapted for use in the current investigation of younger patients. This modied scale comprises 20 items with subscales for facial image, facial prole image, and total body image. For each body part, the respondent uses the original 5-point rating scale devised by Secord and Jourard, with verbal descriptions ranging from 1 (wish I could change it) to 5 (consider myself very fortunate in this area). The Harter Self-Perception Scale52 was administered to measure the childs perceived self-concept. This scale comprises 36 items representing six domains: (1) scholastic competence, (2) social acceptance, (3) athletic competence, (4) physical appearance, (5) behavioral conduct, and (6) global self-worth. The items are in a structured alternative format designed to offset the tendency to give socially desirable responses. For each item, two opposite types of children are described (e.g., some children nd it hard to make friends; other children nd it easy to make friends). The respondent must decide which type of child is more similar to him or her and whether the description on that chosen side is sort of true of me or really true of me. Each item is scored from 1 to 4, where a score of 1 indicates low self-concept and 4 indicates high selfconcept. The direction of responses is reversed for half the items to prevent response bias. Total subscale scores have a possible range of 6 to 24. This instrument has been validated with children in the fourth through sixth grades and has shown good test-retest reliability and internal consistency. Norms are available for boys and girls in the same age range as subjects in the current study.52 Perceived severity and type of malocclusion were measured with the use of a series of drawings adapted from a study by Kiyak,53 in which various forms of malocclusion were evaluated for their relative aesthetics. These drawings were modied to include full-face and

to each parent indicated that the child would receive $5 if they both returned the two completed questionnaires. One month after the packets were mailed, reminder postcards were sent to those who had failed to respond. Two weeks later, a second postcard was mailed to families who had not responded to the rst postcard request. In all, 75 completed parent-child questionnaires were received (76% response rate). Variables and Their Measurement The variables of interest in this study were patient and parent demographics, expectations from treatment, childs body image, self-concept and perceptions of malocclusion, as well as parents evaluation of their childrens level of self-care. Some of the instruments used to measure these variables were adapted from previous research, whereas others are standardized psychologic scales. Still others were developed specically for this study. Listed below are these variables and the measures used to assess them. The appendix includes a copy of each instrument. On the childrens questionnaire they were asked to record age, school, current grade, and sex, as well as treatment status, persons involved in treatment decisions (e.g., mother, father, other guardian, dentist, orthodontist, and self), and perceived reasons for undergoing orthodontic treatment. This questionnaire also included a rating of how the child felt about the treatment decision, ranging from 1 (very unhappy with the decision) to 5 (very happy with the decision). The parents questionnaire asked which parent was primarily responsible for the childs orthodontic treatment, which parent the child lives with on a regular basis, and number of siblings. With regard to other family members, parents were asked whether they or any of the childs siblings had undergone orthodontic treatment, and any associated problems or improvements. The parents were asked to state the reasons for orthodontic recommendations for the subject child, type of treatment rendered, and reasons for rejecting treatment (if they had rejected it). For children in orthodontic treatment and those who had completed Phase I, parents were asked to describe any problems the child had experienced with their procedures or follow-up. To assess childrens and parents expectations of orthodontics, good and bad, we adapted a measure of expectancies that had been developed in an earlier study with surgical and conventional orthodontic patients.48 The instrument comprises a list of 15 items representing four dimensions: (1) oral function, (2) social interaction, (3) self-image, and (4) general health. Each item is accompanied by a 8-point scale ranging from 3 (will be much worse after treatment) to 3 (will be much better). The items were developed on the basis of open-ended interviews with patients who had undergone these procedures. They are generalizable to this younger population of orthodontic patients. To accommodate children who had already completed Phase I, we modied the

34 Tung and Kiyak

Table I. Characteristics of 75 parent-child pairs
Child Mean SD age (yr) Grade* Sex Ethnicity Parents Relation to child Parent underwent orthodontics Siblings underwent orthodontics 10.85 0.91 53% 4th, 39% fth 52% female 83.8% white 85.3% mother, 14.7% father 62.2% 44.9%

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

Table III. Primary reasons for referral

Parents Report (%) 42 (56) 13 (17.3) 7 (9.3) 3 (4.0) 3 (4.0) 1 (1.3) 0 (0) 6 (8.0) 75 (100.0) Childs Perception (%) 42 (56) 11 (14.7) 1 (1.3) 7 (9.3) 0 (0) 4 (5.3) 1 (1.3) 9 (12.0) 75 (100.0)

Reason Crowding Overbite Crossbite General malocclusion* Missing teeth Diastema Habits DK/NR Total

*Remaining children were in the third and sixth grades. Mean age at treatment 12.6 yr. Based on 62 children with siblings.

*Includes teeth dont t and problems biting/chewing. 2 Test of association 76.08, df 42, p 0.001.

Table II. Treatment status, based on parents reports

Age referred for orthodontics* Age started Phase I* Age completed Phase I* In Phase I Phase I not yet begun Rejected Phase I *Data expressed as mean SD. 22% completed. 8.6 1.40 9.1 1.20 10.2 1.74 45% 30.3% 2.7%

the distribution and range of parents and childrens responses to each question. Comparisons between parents and children were made with t tests for continuous data and 2 tests of association for categorical data. Comparisons among groups of children (e.g., pretreatment, posttreatment, current-treatment groups) were made with ANOVA and 2 tests of association. RESULTS Characteristics of the Sample

prole representations of children with anterior crowding, anterior diastema, overbite, overjet, and open bite. Fullface and prole drawings of children with normal occlusion were placed on the left side of each page for comparison. The drawings were intentionally made sexneutral, so boys and girls could rate the same images. With the use of two visual-analogue scales, the child was rst asked to indicate how similar his or her face was to the left-hand drawing (i.e., normal occlusion) or the righthand drawing (i.e., malocclusion). Then he or she rated the relative attractiveness of each face (normal vs. malocclusion). Ratings were determined by measuring the distance (in centimeters) from the left of an X placed by the child on each of the 12-cm lines. To assess the parents perceptions of the childs independence in home care and other health and hygiene behaviors, and the childs ability to adhere to the orthodontists recommendations with regards to home care and appliance wear, we adapted a brief questionnaire from a scale constructed by Sparrow and colleagues.54 The original scale was implemented to assess the independence of developmentally disabled persons. The modied instrument consists of 21 activities that any child may perform. The parent is asked to rate the childs independence in performing each task, using a 5-point response scale. A response of 1 indicates that the child needs assistance while a score of 5 indicates that the child can perform the activity totally independently. Simple descriptive statistics were used to determine

The sample consisted of 75 children and their parents. Table I summarizes the major demographic characteristics of these respondents. Children ranged in age from 8.75 to 12.5, with a mean of 10.850.91 years. Most had recently completed fourth grade (53%) and were from the Seattle area (84%); the remainder live in Anchorage, Alaska. Most children reported themselves as white (84%), with a small number of children who identied themselves as black (1.33%), Asian (4.0%), Hispanic (2.7%), or of mixed ethnicity (8.0%). In all subsequent analyses these ethnic minorities were combined and compared with white subjects. Of the 75 parent questionnaires returned, 64 (85.3%) were completed by the mother of the child, and 71 (94.7%) parents reported that the child resides with both the mother and the father. According to their parents, the average age of respondent children at the time of referral for Phase I was 8.6 years. Most were either still in Phase I therapy (45%) or had completed it (22%). Another 30.3% were expecting to begin Phase I in the coming year, whereas only two (2.7%) had decided not to undergo Phase I treatment (Table II). The primary reasons for referral as reported by both parent and child are presented in Table III. Childrens perceptions of why they needed orthodontics were consis-

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No. 1

Tung and Kiyak 35

Fig. 3. Childrens aesthetic rating scale. Sample malocclusion: crowding.

tent with the diagnosis as reported by their parents (2 76.08, df 42, p .001). The primary diagnosis, as reported by parents, was crowded teeth (56%), followed by overbite (17.3%). The least frequently mentioned problems were oral habits (n 0), missing teeth and generalized malocclusion (n 3 each). Children were especially likely to describe crossbite as poorly tting teeth or as problems with biting into foods. It is noteworthy that nine children and six parents did not know why the child had been referred for orthodontics; all nine of these children were in treatment at the time the questionnaire was administered. When asked to rate themselves on a visualanalogue scale comparing normal occlusion with one of ve types of malocclusion, children generally

perceived themselves in the normal range. Mean scores and SDs on these self ratings (shown for one type of malocclusion in Fig. 3) are in a relatively narrow range. That is, despite their ability to describe verbally their particular occlusal deviation that necessitated treatment, these children viewed themselves in the normal range when given drawings illustrating childrens faces with normal occlusion vs. illustrations of malocclusion matching their own condition.
Parents, Siblings, and Childrens Experiences With Orthodontics

Among the children with siblings, 44.9% of these siblings had undergone orthodontic treatment. Among the parents themselves, 65.2% reported

36 Tung and Kiyak

Table IV. Expectations from orthodontics (N 75 pairs)
Feature Self-image* Oral function Social life General health Parent (Mean SD) 6.33 3.38 6.00 3.67 1.55 2.36 0.27 1.04 Child (Mean SD) 4.23 3.66 3.78 3.97 0.93 2.29 0.41 1.34 p 0.0001 0.0001 0.03 NS

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

Table VI. Body-image correlations (N 75 children)

Harter physical-appearance category x Total body image x Facial body image x Prole body image r 0.50 0.33 0.43 p 0.0001 0.004 0.0001

*Summary scores may range from 12 (expect much decline) to 12 (expect much improvement).

Table VII. Ethnic differences in aesthetic ratings

Malocclusion White (n 63) 1.21 1.65 0.99 1.21 1.55 Ethnic minorities (n 12) 2.53 2.53 1.67 1.95 1.99 p 0.02 0.02 0.01 0.07 NS

Table V. Harter self-perception scores

Norms* Parameter Scholastic competence Social acceptance Athletic competence Physical appearance Behavioral conduct Global self-worth Female 2.79 2.82 2.73 2.74 3.22 2.90 Male 2.77 2.93 3.14 3.14 2.79 3.02 Sample (N 75) Female 3.24 2.89 2.97 3.09 3.30 3.45 Male 3.27 3.08 3.12 3.35 3.27 3.44

Crowded teeth Overbite Diastema Overjet Open bite

*Based on average of fourth- and fth-graders in national sample.

having undergone orthodontic treatment (mean age at treatment 12.6 years). In general, most parents did not recall having had problems with their orthodontic treatment. Most commonly, they reported that orthodontics had improved their self-concept and oral function. Parents also reported that their other children who had undergone orthodontics did not experience major problems; however, they were more likely to report that their other children had had functional problems with orthodontic appliances than they had personally experienced (33% of siblings with orthodontics). The parents also described greater improvements in these siblings oral function and appearance than in themselves (26.6%). Parents recollection of their own and siblings problems were found to be related (2 18.75, df 9, p 0.03). Parents were also asked to describe any problems the subject child was having with orthodontics. The largest group (42.3%) apparently had had no problems. Another 38.5% reported some pain and discomfort (44% when combined with those who had completed Phase I orthodontics). Some were having problems with retainers (15.4% of active patients, 27% of patients who had completed treatment). Compliance problems were noted by only four parents (5.33%). Childrens self-ratings of their satisfaction with treatment decisions revealed generally neutral feelings regarding treatment (mean 3.56, df 72, SD

1.13). However, signicant sex-related differences emerged in satisfaction scores (t 2.11, p .05); girls reported greater satisfaction with the decision to undergo treatment. White children reported greater satisfaction with the decision than did children of ethnic-minority background (t 2.96, df 70, p .002).
Expectations From Treatment

The 14-item measure of expectations from orthodontics was analyzed along the four dimensions represented by the items. Table IV illustrates childrens and parents expectations for each of the four dimensions and the results of t tests comparing their responses. The mean ratings by children and their parents indicate the greatest expectation of improvement in self-image (e.g., appearance, selfcondence) and oral function (e.g., better chewing and occlusion) but little or no change in the childs social life or general health. Note that mean scores revealed an expectation of improvement or no change in all areas; very few children and no parents expected orthodontics to impair their quality of life. Although parents and childrens rank orders of expectations in these four dimensions were identical, their mean scores differed. Parents expected greater improvements in the childs self-image (t 4.58, p .0001), oral function (t 4.35, p .0001), and social life (t 2.19, p .03) than did their children. Neither children nor their parents expected much change in the childs general health as a function of orthodontics.
Self-Concept and Body Image

Childrens ratings of their self-concept on the Harter Self-Perception Scale52 were summarized

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No. 1

Tung and Kiyak 37

along the six dimensions specied by the scale and compared with the normative samples of fourth- and fth-graders tested by Harter. As shown in Table V, our sample scored higher than or equal to the normative samples on all six dimensions. It is noteworthy that their global self-worth scores, representing the childs overall perceptions of self-esteem, was higher than any component score, whereas for the normative sample this global selfworth score was in the intermediate range. Selfesteem with regard to physical appearance was somewhat lower among girls than boys in this sample (t 1.66, df 73, p .10) but higher than that of the normative sample. Body-image scores were also in the intermediate to high range for this sample. Mean scores were high for the facial body-image items (mean 3.45, SD 0.74), for overall (mean 3.48, SD 0.71) and for prole image (mean 3.58, SD 0.91). Comparisons among children who had completed treatment, those who were in treatment, and those who were not in treatment revealed no differences in bodyimage scores. Not surprisingly, all three components of body image were highly correlated with the physical-appearance dimension of the Harter SelfPerception Scale. As shown in Table VI, the higher a childs self-rating of his or her prole, facial features, and overall body image, the higher the scores on the physical-appearance items of the Harter Scale.
Ethnic Differences

independent in areas such as dressing themselves (mean 4.93, SD 0.31) and fastening their seat belts when riding in a car (mean 4.80, SD 0.53). They were considered least independent in areas such as performing household chores (mean 3.22, SD 0.71) and cleaning their rooms (mean 3.0, SD 0.9). Parents rated their children as relatively independent in the care of their teeth (e.g., brushing and ossing) and in other areas of personal hygiene (mean 4.2, SD 0.93 and mean 4.0, SD 0.9, respectively).
DISCUSSION

Children who described their ethnicity as white were compared with ethnic-minority children. Although the latter group represented only 16% of the total sample, they differed signicantly from the former group in their ratings of the attractiveness of malocclusion. As shown in Table VII, ethnic minorities rated the faces more positively; differences were signicant for crowded teeth (p 0.02), overbite (p 0.02), and diastema (p 0.01) and marginally signicant for overjet (p 0.07). However, they did not rate themselves more negatively than white children on these dimensions, nor did they score lower on body image and self-concept.
Parents Perceptions of Childrens Self-Care Abilities

Parents perceptions of their childrens ability to perform various self-care activities indicated that most believed their children were generally independent in self-care (mean range 3.0 to 4.93). On a scale of 1 to 5, children were reported to be most

The literature on personality development and on the psychological aspects of physical appearance reviewed earlier suggests that preadolescent children are at a stage of developing a sense of selfcondence and competence. They are aware of their own physical appearance and that of their peers. They can accurately describe their own facial features. Another strength of this stage of development is that these children are more focused on the future, less concerned about peer approval than are adolescents. They generally are still seeking the approval of signicant adult role models (e.g., parents, health care providers); as a result they are more likely to adhere to rules and daily routines established by adults. The ndings of this study support theories of developmental psychology. Although we did not compare preadolescents with adolescents undergoing orthodontic treatment, it is apparent that children ages 9 to 12 have many psychosocial strengths that make them ideal candidates for Phase I treatment. The children in this study were generally aware of the type of occlusal condition for which they had been referred for treatment. They agreed with the diagnosis (as reported by parents) in almost 80% of cases, although 12% could not explain their condition at all. Contrary to the work of Shaw and colleagues,17,18 who found that children in the United Kingdom were most likely to be referred for orthodontic treatment of a large overjet (7.0 mm), the ndings of this study indicate that a low percentage of children were referred for treatment of this condition. Most children and their parents reported that crowding of teeth was the primary reason for referral (56%), followed by overbite (17.3%). It may be that these parents and children attributed overjet to crowding and overbite. These ndings are more consistent with those of Helm and colleagues19 in Denmark, who found that overbite was a common reason for treatment to be sought.

38 Tung and Kiyak

American Journal of Orthodontics and Dentofacial Orthopedics January 1998

Subject children scored higher on the self-concept measure than did population norms for their age, and they scored higher than previous studies of patients seeking treatment. Furthermore, we found no differences in self-concept scores between children waiting for treatment, those who had completed treatment, and those in active treatment. This nding is consistent with those of studies with orthognathic-surgery patients reported by Kiyak and Bell6 and with studies of conventional orthodontic patients reported by Albino and colleagues31 and Dann and colleagues.37 On comparison of the specic domains of self-concept, scores were highest on perceived global self-worth, behavioral conduct, and scholastic achievement. Self-concept with regard to physical appearance was intermediate in mean scores, followed by the self-ratings on social acceptance and athletic competence. Even on these dimensions of self-concept, however, these children rated themselves more positively than the normative sample of non-orthodontic patients. In general, childrens body image scores were high and were correlated with the childs physical appearance selfconcept. This correlation may be reective of the patients being in treatment or anticipating treatment, which promotes a tendency to see changes in themselves even before completing Phase I orthodontics. One possible reason for the high self-concept and body-image scores in this sample is that these children had not yet reached adolescence, when many enter the stage of role confusion or identityseeking. Their high scores may be a reection of the increased sense of competence found at the preadolescent stage. Alternatively, these children may have been gaining their self-condence by seeing the improvements that orthodontics was making in their appearance. It may be that they will never experience the traumas of adolescence as described by Erikson and Freud.43,44 Ethnic-minority children assigned more positive ratings than did white children to drawings representing various malocclusions. This nding is consistent with data from a previous study in which ethnic differences in perceptions of various malocclusions by white and Asian adults were assessed.53 These similarities are striking when one considers that these two samples differed widely from each other (i.e., middle- and upper-income children seeking orthodontic correction in our study, compared with low-income adults who had never undergone orthodontics in the earlier study). Such similarities suggest that cultural differences inuence esthetic

values. Coupled with the ndings of studies by Soh and Lew24 and Wheeler et al.,27 these studies indicate a need for more research with ethnic-minority children referred for orthodontic interventions. To what extent does the need for treatment as determined by an orthodontist conict with that childs value system and desire for orthodontics? Finally, the ndings that most parents in this sample had undergone orthodontic treatment (65.1%) and that 48.4% with siblings had undergone treatment suggests that this may be a segment of the population that is more informed about the need for and benets of orthodontic treatment than the general population. Given their past experience with orthodontics, these parents and their children may not be unrealistic in expecting this procedure to have a positive impact on their social lives and their image of themselves. Indeed, perhaps these children represent an ideal patient population; both their parents and siblings have experienced orthodontics, albeit at a later age than the child. These childrens self-reports may have a more realistic basis than the child who undergoes Phase I treatment with no preparation by parents, siblings, or peers. The results of this study suggest that such children fare very well with Phase I treatment; they appear to adhere to home care and appointment-keeping behaviors and are supported in their orthodontic experiences by informed parents.
The authors acknowledge the valuable suggestions offered by several orthodontic colleagues in designing this study and developing the questionnaires. In particular, we thank Dr. Rebecca Poling, Dr. Anne-Marie Bollen, and Dr. Douglas Ramsay. We also thank members of CDABO who attended the annual meeting in Quebec City in July 1997 and gave the authors valuable feedback on the preliminary results.

REFERENCES 1. Albino JE, Alley TR, Tedesco LA, Tobiasen JA, Kiyak HA, Lawrence SD. Esthetic issues in behavioral dentistry. Ann Behav Med 1990;12:148-55. 2. Goffman E. Stigma: notes on management of spoiled identity. Englewood Cliffs, N.J.: Prentice Hall, 1963. 3. Vander Zanden JW. Human development. New York: Alfred A. Knopf, 1985. 4. Kagan J. Perspectives on human infancy. In: Osofsky JD (ed). Handbook of infant development. New York: Wiley, 1979. 5. Carvior N, Lombardi DA: Developmental aspects of judgment of physical attractiveness in children. Dev Psychol 1973;8:67-71. 6. Kiyak HA, Bell R. Psychosocial considerations in surgery and orthodontics. In: Prott WR, White R (eds). Surgical-orthodontic treatment. St. Louis: MosbyYear Book, 1990:71-91. 7. Dare GJ. The effect of pupil appearance on teacher expectations. Early Child Dev Care 1992;80:97-101. 8. Adams GR, Crane P. An assessment of parents and teachers expectations of preschool childrens social preference for attractive and unattractive children and adults. Child Dev 1980;51:224-31. 9. Dion K, Berscheid E, Walster E. What is beautiful is good. J Pers Soc Psychol 1972;24:285-90.

American Journal of Orthodontics and Dentofacial Orthopedics Volume 113, No. 1

10. Goldman W, Lewis P. Beautiful is good: evidence that the physically attractive are more socially skillful. Exp Psychol 1977;13:125-30. 11. Langlois JH, Stephan C. The effects of physical attractiveness and ethnicity on childrens behavioral attributions and peer preferences. Child Dev 1977;48:1694-8. 12. Landy D, Sigall H. Beauty is talent: task evaluation as a function of the performers physical attractiveness. J Pers Soc Psychol 1974;29:299-304. 13. Bull R, Rumsey N. The social psychology of facial appearance. New York: Springer-Verlag, 1988. 14. Cross JF, Cross J. Age, sex, race and the perception of facial beauty. Dev Psychol 1971;5:433-9. 15. Linn EL. Social meanings of dental appearance. J Health Hum Behav 1966;7:289-95. 16. Berscheid E, Walster E, Bohrnstedt G. Body image. Psychol Today 1973;7:119-31. 17. Shaw WC. The inuence of childrens dentofacial appearance on their social attractiveness as judged by peers and lay adults. Am J Orthod 1981;79:399-415. 18. Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod 1980;7:75-80. 19. Helm S, Kreiborg S, Solow B. Psychosocial implications of malocclusion: a 15 year follow-up study on 30-year-old Danes. Am J Orthod 1985;87:110-8. 20. Kilpelainen PV, Phillips C, Tulloch JF. Anterior tooth position and motivation for early treatment. Angle Orthod 1993;639:171-4. 21. Tedesco LA, Albino JE, Cunat JJ, Green LJ, Lewis EA, Slakter MJ. A dental-facial attractiveness scale. Am J Orthod 1983;83:38-43. 22. Dongieux J, Sassouni V. The contribution of mandibular positioned variation to facial esthetics. Angle Orthod 1980;50:334-9. 23. Wilmont JJ, Barber HD, Chou DG, Vig KW. Associations between severity of dentofacial deformity and motivation for orthodontic-orthognathic surgery treatment. Angle Orthod 1993;63:283-8. 24. Soh G, Lew KK. Assessment of orthodontic treatment needs by teenagers in an Asian community in Singapore. Commun Dent Heal 1992;9:57-62. 25. Gosney MB. An investigation into some of the factors inuencing the desire for orthodontic treatment. Br J Orthod 1986;13:87-94. 26. Spencer AJ, Allister JH, Brennan DS. Predictors of xed orthodontic treatment in 15-year-old adolescents in South Australia. Comm Dent Oral Epidemiol 1995;23: 350-5. 27. Wheeler TT, McGorray SP, Yurkiewicz L, Keeling SD, King GJ. Orthodontic treatment demand and need in third- and fourth-grade schoolchildren. Am J Orthod Dentofac Orthop 1994;106:22-33. 28. Holmes A. The subjective need and demand for orthodontic treatment. Br J Orthod 1992;19:287-97. 29. Novick N, Cauce AM, Grove K. Competence self-concept. In: Bracken B (ed). Handbook of self-concept. New York: Wiley, 1995. 30. Gecas V. The self-concept. Annu Rev Soc 1982;8:1-33. 31. Albino JE, Lawrence SD, Tedesco LA. Psychological and social effects of orthodontic treatment. J Behav Med 1994;17:81-98. 32. Albino JE, Lawrence SD. Promoting oral health in adolescents. In: Millstein SG, Petersen AC, Nightingale EO (eds). Promoting the health of adolescents: new directions for the 21st century. New York: Oxford University Press, 1993:242-59.

Tung and Kiyak 39

33. Petersen AC, Tobin Richards M, Boxer AM. Puberty: its measurements and its meanings. J Early Adolesc 1983;3:47-62. 34. Klima RJ, Wittemann JK, McIver JE. Body image, self-concept, and the orthodontic patient. Am J Orthod 1979:75:507-16. 35. Story RI. Psychological issues in orthodontic practice. Am J Orthod 1966;52:584-98. 36. McKiernan EXF, McKiernan F, Jones ML. Psychological proles and motives of adults seeking orthodontic treatment. Int J Adult Orthod Dentofac Orthog 1992;7:187-98. 37. Dann C, Phillips C, Broder HL, Tulloch JF. Self-concept, class II malocclusion, and early treatment. Angle Orthod 1995;65:411-16. 38. Jones JE. Self-concept and parental evaluation of peer relationships in cleft lip and palate children. Pediatr Dent 1984;6:132-8. 39. Tobiasen JM, Levy J, Carpenter MA, Hiebert JM. Type of facial cleft, associated congenital malformations, and parents ratings of school and conduct problems. Cleft Palate J 1987;24:209-15. 40. Cucalon A III, Smith RJ. Relationship between compliance by adolescent orthodontic patients and performance on psychological tests. Angle Orthod 1990;60:107-14. 41. Southard KA, Tolley EA, Arheart KL, Hackett-Renner CA, Southart TE. Application of the Millon adolescent personality inventory in evaluating orthodontic compliance. Am J Orthod Dentofac Orthop 1991;100:553-61. 42. Weiss J, Eiser HM. Psychological timing of orthodontic treatment. Am J Orthod 1977;72:198-204. 43. Erikson E. Identity: youth and crisis. New York: Norton, 1968:165. 44. Freud A. Adolescence. Psychoanal Stud Child 1958;16:225-78. 45. Waterman AS. Identity development from adolescence to adulthood: an extension of theory and review of research. Dev Psychol 1982;18:341-358. 46. Blyth DA, Traeger CM. The self-concept and self-esteem of early adolescents. Theory Into Practice 1983;22:91-7. 47. Peevers BH: The self as observer of the self: a developmental analysis of the subjective self. In: Honess T, Yardley K (eds). Self and identity: perspectives across the lifespan. New York: Routledge & Kegan Paul, 1987:147-71. 48. Ostler S, Kiyak HA. Treatment expectations versus outcomes among orthognathic surgery patients. Int J Adult Orthod Orthog 1991;6:247-55. 49. Phillips C, Broder HL, Bennett ME. Dentofacial disharmony: motivation for seeking treatment. Int J Adult Orthod Orthog Surg 1997; 12:7-15. 50. Kiyak HA, Zeitler DL. Self-assessment of prole and body image among orthognathic surgery patients before and two years after surgery. J Oral Maxillofac Surg 1988;46:365-71. 51. Secord PF, Jourard SM. The appraisal of body cathexis and the self. J Cons Psych 1953;17:343-47. 52. Harter S. Manual for the self-perception prole for children. Denver, Colo.: University of Colorado, 1985. 53. Kiyak HA. Comparisons of esthetic values among Caucasians and Pacic-Asians. Commun Dent Oral Epidemiol 1981;9:219-23. 54. Sparrow SS, Balla DA, Cicchetti DV. Vineland adaptive behavior scale. Circle Pines, Minn.: American Guidance Service, 1984.